[Cancer and infertility]. / Kræft og infertilitet.

Patients with cancer are at risk of loss of gonadal function due to the cancer treatment. Chemo- and radiation therapy are known to induce gonadal failure in both men and women and especially treatment with alkylating agents and/or abdominal or testicular radiation therapy poses a high risk. Methods exist to preserve fertility and these should be discussed with and offered to the patient if necessary and possible. For men, cryopreservation of semen is simple, non-invasive and low-cost. For women, cryopreservation of oocytes, embryos or ovarian tissue is an option in order to preserve fertility.

Cryopreservation of ovarian tissue for fertility preservation in young female oncological patients.

Girls and women suffering from a cancer that requires treatment with gonadotoxic drugs may experience cessation of reproductive function as a side effect due to obliteration of the ovarian pool of follicles. Techniques are now available for fertility preservation, such as cryopreservation of mature oocytes, embryos or ovarian cortical tissue. Whereas collection of mature oocytes and embryos requires at least a 2-week period, ovarian tissue may on short notice be frozen prior to treatment and can be transplanted back into women with ovarian failure. Transplanted frozen/thawed tissue supports survival and growth of follicles, giving rise to menstrual cycles and hormone production for several years. Worldwide, the procedure has resulted in the birth of 15 healthy children. Many cancer patients including girls and young women want fertility preservation, and the techniques are now being further developed and implemented in several centers.

Recommendations for fertility preservation in patients with lymphomas.

PURPOSE: This guideline aims to serve as a reference for fertility specialists and other specialists working with young patients at risk of premature ovarian insufficiency (POI) or testicular dysfunction (TD) due to treatment of Hodgkin or Non-Hodgkin lymphoma. METHODS: PubMed search of articles addressing risk of POI and TD according to different treatment protocols used in lymphoma patients. PubMed search of articles presenting different options for fertility treatment in cancer patients. RESULTS: The risk of POI/TD depends on the protocol used with the highest risk in patients treated with haematopoietic stem cell transplantation/bone marrow transplantation (HSCT/BMT) and the lowest risk in patients treated with ABVD (Adriamycin, Bleomycin, Vincristine and Decarbazine). The different options of fertility preservation are discussed and their relevance according to treatment protocol, age of the patient and urgency to start treatment. CONCLUSION: Fertility issues should be discussed with all women of fertile age. Fertility preservation should be offered to young women when relevant. Children should be informed together with their parents. All men should be offered semen cryopreservation regardless of protocol used. At present, there are no established methods of fertility preservation in pre-pubertal boys. This guideline offers suggestions to the most preferred methods of fertility preservation according to treatment protocol, age of the patient, and urgency to start treatment.

Evaluation of the ovarian reserve in women transplanted with frozen and thawed ovarian cortical tissue.

OBJECTIVE: To investigate ovarian reserve and ovarian function in women transplanted with frozen/thawed ovarian tissue. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENT(S): 18 women transplanted with their own frozen/thawed ovarian tissue. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Levels of antimüllerian hormone (AMH), duration of function of the transplanted ovarian tissue, outcome of assisted reproduction. RESULT(S): Of the 18 women who received transplanted ovarian tissue, levels of AMH were measured in 12 women; AMH never exceed a concentration of 1 ng/mL, and in several cases they were below the detection limit of the assay in combination with regular menstrual cycles. Two women with AMH below the detection limit conceived spontaneously. The duration of function of the transplants was between 9 months and 7 years and still functioning. Twelve women received assisted reproduction therapy; in 72 cycles, 65 oocytes were retrieved. The pregnancy rate and live-birth rate per cycle were 6.9% (5 of 72) and 2.8% (2 of 72), respectively. CONCLUSION(S): The relatively poor outcome of assisted reproduction in women transplanted with frozen/thawed ovarian tissue may reflect reduced follicular selection rather than defective or aged oocytes. In normal women, reduced follicular selection with age may be part of explaining the decline in female fecundity with increasing age.

Cryopreservation of ovarian tissue for fertility preservation: no evidence of malignant cell contamination in ovarian tissue from patients with breast cancer.

Cryopreserved ovarian cortical biopsies from 51 patients with breast cancer were examined by histologic and immunohistochemical analysis and showed no sign of metastases. Autotransplantation of ovarian cortex to patients with low-stage breast cancer disease appears safe, but confirmatory studies are required, including xenotransplantation studies.

Cryopreservation of ovarian tissue for a decade in Denmark: a view of the technique.

This paper presents the Danish 10-year experience (1999-2009) with cryopreservation (n=386) and autotransplantation of ovarian tissue (n=18). Before applying the technique to humans, the method was thoroughly tested and validated. The cryoprotectant solution was chosen after histological evaluation of mouse and human ovarian tissue after freezing with four different combinations of cryoprotectants. Viability was confirmed by transplantation of frozen-thawed human ovarian tissue (n=49) to oophorectomized Nude mice. Viability after transport of fresh tissue 4-5h prior to freezing had previously been validated. Overnight transport of fresh ovarian tissue prior to cryopreservation was evaluated when human ovarian tissue was kept on ice for 20h and then cryopreserved. The thawed ovarian tissue was transplanted to an oophorectomized Nude mouse and histology confirmed viability. In Denmark 12 women have received a total of 18 autotransplantations of ovarian tissue. All women resumed ovarian function and three healthy babies were born to two women. In both women, the tissue was transported on ice for 4-5h prior to cryopreservation. Ovarian tissue cryopreservation is an important method for fertility preservation; however, before applying the method clinically, each laboratory should perform thorough validation of their technique.

Autotransplantation of cryopreserved ovarian tissue in 12 women with chemotherapy-induced premature ovarian failure: the Danish experience.

OBJECTIVE: To describe a cohort of 12 Danish women who received autotransplantation of frozen-thawed cryopreserved ovarian tissue because of premature ovarian failure after cancer treatment. DESIGN: Retrospective study. SETTING: University hospitals. PATIENT(S): Twelve women with autotransplanted frozen-thawed ovarian tissue. INTERVENTION(S): Monitoring of hormonal parameters and results of 56 IVF cycles in 10 women. MAIN OUTCOME MEASURE(S): Levels of gonadotropins and sex steroids, functional life span of the grafts, and results of IVF. RESULT(S): All 12 women regained ovarian function between 8 and 26 weeks (mean 19 weeks) after transplantation. Ten women underwent a total of 56 IVF cycles, 76 follicles developed, 49 oocytes were aspirated, 18 were fertilized, and 16 embryos were transferred resulting in six pregnancies: two biochemical, one clinical that miscarried in week 7, and two ongoing resulting in the delivery of two healthy infants born at term to two women. One of these women subsequently conceived spontaneously and delivered another healthy infant. The life span of the transplanted tissue has been between 6 months and still functioning after 54 months. CONCLUSION(S): Autotransplantation consistently leads to recovery of ovarian function after treatment-induced ovarian failure. Four women became pregnant, after IVF or spontaneously, resulting in the delivery of three healthy infants.

Concentrations of AMH and inhibin-B in relation to follicular diameter in normal human small antral follicles.

BACKGROUND: The aim of the present study was to determine the intrafollicular concentrations of anti-Müllerian hormone (AMH), inhibin-B and steroids in normal human small antral follicles and to relate them to follicular size. METHODS: A group of 103 women having one ovary removed for fertility preservation by cryopreservation prior to gonadotoxic treatment served as a source of a total of 272 human small antral follicles. Prior to cryopreservation of the ovarian cortex, fluid from small antral follicles were collected. On the basis of the follicular volume, the diameter was calculated and follicles with diameters from 3 to 12 mm were included. RESULTS: Concentrations of AMH decreased significantly (P < 0.0005) from 1124 +/- 158 ng/ml (mean +/- SEM) in follicles with a diameter of 3 mm to a concentration of 392 +/- 98 ng/ml in 9 mm follicles, followed by a reduction to below 100 ng/ml in 12 mm follicles. The concentrations of inhibin-B rose from 57 +/- 10 ng/ml (mean +/- SEM) in 3 mm follicles to 142 +/- 10 ng/ml in 12 mm follicles (P < 0.0005) with a peak concentration of almost 200 ng/ml in 9-10 mm follicles. Relating hormone concentrations with age showed that even follicles from girls younger than 10 years showed the same range of AMH concentrations as those from older girls or women. CONCLUSIONS: The intrafollicular concentrations of AMH become progressively lower with increasing follicle diameters. In contrast, concentrations of inhibin-B increased with increasing follicle diameter with peak values at around 9 mm in diameter. This suggests that AMH and inhibin-B undertake important intrafollicular functions around the time of normal follicular selection in the mid-follicular phase of the menstrual cycle.